MOOD DISORDERS BIPOLAR DISORDER DMDD AGGRESSION AND SIB
MOOD DISORDERS (BIPOLAR DISORDER, DMDD), AGGRESSION, AND SIB Joshua Proemsey, MD Child and Adolescent Psychiatry Fellow, PGY-5 Division of Child and Adolescent Psychiatry Department of Psychiatry University of Florida
BIPOLAR DISORDER: CLINICAL CHARACTERISTICS • Mood disorder characterized by mood swings between manic and depressive states • Mood swings are episodic • A portion of youth will meet full criteria for Bipolar Disorder although criteria were not designed for Pediatric Populations • Normal children will exhibit manic or hypomanic symptoms
BIPOLAR DISORDER: SUBTYPES • • Bipolar I Disorder: • Episodes of mania and depression (14+ days of depression) • Mixed episodes can occur Bipolar II Disorder: • • Episodes of hypomania and depression Cyclothymia: • Duration of 1 year with more than half time with episodes of elevated or depressed mood • Periods of euthymic mood less than 2 months
BIPOLAR DISORDER: CLINICAL CHARACTERISTICS • Mania: • Duration: 1 week • Hypomania: • A) distinct period elevated, expansive or irritable mood • Duration: 4+ days • AND persistent increase in goal directed activity or energy • A) distinct period elevated, expansive or irritable mood • AND persistent increase in goal directed activity or energy • B) Same as B for mania • C) Unequivocal change from baseline • Distractibility • D) Noticeable by others • Increase in goal directed activity or psychomotor agitation • E) Not severe enough to cause significant impairments, hospitalization and no psychotic features • B) 3 of following symptoms or 4 of following if mood irritable: • Inflated self-esteem or grandiosity • Decreased need for sleep • More talkative than usual or pressure to keep talking • Flight of ideas or racing thoughts • Excessive involvement in pleasurable activities • C) Impairment in functioning or psychosis
BIPOLAR DISORDER: MANIC SYMPTOMS • Average on onset 11. 5 years old • Most common symptoms; increased energy, irritability, mood lability, distractibility and goal directed activity • Least frequent: hypersexuality, hallucinations, delusions • Most specific: Grandiosity and Hypersexuality • Low specificity: Irritability (common in depression, DMDD, anxiety, PTSD)
BIPOLAR DISORDER: EPIDEMIOLOGY • 60% of adults with BP had a mood episode prior to age 20 • Prevalence: • Pediatric BP-I and BP-II between 1 -2% • Increased prevalence during late adolescence
BIPOLAR DISORDER: NEUROBIOLOGY • Disturbance in Glutamate and GABA in Frontostriatal, Cingulate, DLPFC • Neuroimaging: • • Emotional dysfunction a/w hyper activation of amygdala, PFC, visual • Cognitive Deficits related to hypo activation of anterior cingulate cortex Areas of interest: • Dysfunction in Emotion Processing (PFC-hippocampal-amygdala circuit) • Overactivation of reward processing circuit (left ventral striatal-vl. PFC-OFC)
BIPOLAR DISORDER: RISK FACTORS • Parents with diagnosed BP • Higher rates of bipolar spectrum disorders (23% vs 3%) • Higher rates of BP-I (13% vs 1. 5%) • Offspring with mood lability, subsyndromal manic symptoms and parents with early onset BP approximately 50% risk to develop • Genetic Etiology for BP • Heritability over 80%
BIPOLAR DISORDER: RISK FACTORS • Risk for bipolar in early onset depression is 10 -20% • Higher risk of conversion to BP in patients with depression when: • History of antidepressant-induced or spontaneous hypomania • Psychotic features • Hypomania • Family history of bipolar • Psychosocial factors: • Low SES, exposure to trauma, stressful family environment
BIPOLAR DISORDER: COMORBIDITIES • ADHD - 53% • ODD - 42% • Conduct Disorder - 27% • Anxiety Disorders - 23% • Substance Abuse - 9%
BIPOLAR DISORDER: DDX • ADHD • DMDD • ODD / Conduct • Unipolar Depression • ASD • Schizophrenia • Substance Use Disorder • Borderline Personality Disorder
BIPOLAR DISORDER: DDX • Confusion most often ADHD or Behavioral Disorders • BP: symptoms of euphoria, grandiosity, decreased need for sleep, hyper sexuality (without h/o abuse), and hallucinations • Shared sxs: increased energy, irritability, and aggression • More severe in BP youth • Other areas: Fhx of Bipolar, response to antidepressants
BIPOLAR DISORDER: DDX • ADHD vs Bipolar Recurrent mood swings, outbursts, rages • Later onset of symptoms (10+) Hallucinations or delusions • Symptoms appear abruptly FHx of bipolar • Responded to stimulants and now not responding • Symptoms are episodic and a/w mood changes
BIPOLAR DISORDER VS DMDD • Behavior problems only occur during an episode of mania or depression • “Off and on” oppositional or conduct symptoms • Severe behavioral problems that do not respond to treatment
BIPOLAR DISORDER: TREATMENT OF MANIA / MIXED EPISODES First Line: • • Start with FDA Approved 10 -17: • • Abilify, Risperdal, Quetiapine, Asenapine • Best data for Risperdal Partial Response to single atypical: • Augment with Lithium No response: • Switch to another FDA approved antipsychotic or Olanzapine • Switch to lithium
BIPOLAR DISORDER: DEPRESSION • FDA Approved: Latuda and Fluoxetine / Olanzapine combination • First, use Latuda • If fails, use combination Fluoxetine / Olanzapine • If fails, use Lamictal • Based upon adult evidence. Evidence sparse in children.
BIPOLAR DISORDER: PSYCHOSOCIAL TREATMENT • Psychoeducation: disease management • Interpersonal and Social Rhythm Therapy (IPSRT) • Cognitive approaches to stress management, emotional regulation and interpersonal conflict • Highlights mood regulation causing dysfunction in relationships • Discussed regulating sleep and daily rhythms to improve mood regulation and functioning • Dialectical Behavioral Therapy (DBT) • Focus on emotional regulation and mindfulness
DISRUPTIVE MOOD DYSREGULATION DISORDER • Recurrent temper outbursts with negative mood state • Diagnostic Criteria: • Characterized by frequent, severe, recurrent, temper outbursts and chronically irritable and/or angry mood • At least 3 temper outbursts per week • Onset aged 6 and no older than 10 years old • Must be present for at least 1 year without a symptom free interval of 3 or more months • Symptoms presents in 2 of 3 settings: home, social, school
DMDD: COURSE • Chronic irritability in early adolescence predicted ADHD in late adolescence and depression in early adulthood • Difference between chronic and episodic irritability • DMDD increases risk for depression and anxiety in adulthood • DMDD does not increase the risk for Bipolar Disorder
DMDD: EPIDEMIOLOGY • Lifetime prevalence approx 0. 8 - 3. 3% • Prevalence decreases with age • Children with DMDD usually male and younger
DMDD: RISK FACTORS FHx: Stressful events: Substance abuse or Psychopathology Early life trauma Maternal history of peripartum depression Recent h/o divorce, grief Nutritional Iron deficiency, B 12 def, Folate def
DMDD: PATHOPHYSIOLOGY • Not currently great data specifically on DMDD although data on SMD • Hyperarousal elicited by frustrating stimuli • During facial affect recognition task, DMDD showed excessive amygdala activation for all faces compared to BP where excessive activation only occurred with fearful faces
DMDD: COMORBIDITIES • ODD - 96% • ADHD - 81% • Anxiety Disorders - 58% • Conduct Disorder - 13%
DMDD: NON-PHARMACOLOGICAL TREATMENT • Psychotherapeutic Interventions • Target impairment in social functioning and emotional dysregulation • Behavioral Therapy and Parent Management Training • DBT-C - DBT adapted for adolescents include parent training component
DMDD: PHARMACOLOGICAL TREATMENT • Evidence limited overall • 1 st Treat Comorbid Disorders such as ADHD, depression, anxiety if present • Antidepressants (SSRI) • • • Useful in treating comorbid anxiety and depression Improved chronic and persistent irritability Remember, DMDD does not have increased rates of bipolar so no increased concern for causing mania • Methylphenidate (MPH) • Useful for treating comorbid ADHD and improving aggression • Optimize medication based upon weight, tolerability and side effects • Second Generation Antipsychotics (Abilify / Risperdal) • Improved irritability and aggression • Concern for side effects
AGGRESSION • Aggression and/or irritability is common in many Psychiatric disorders • Comprehensive Assessment • Modified Overt Aggression Scale (MOAS) - track changes • 1 st Step - Psychosocial Treatment • Parent Management Training (PMT), Parent Child Interaction Training (PCIT), behavioral therapies such as ABA • Multimodal interventions such as Multisystemic Therapy • Cognitive Behavioral Therapy (CBT) • Family Therapy
AGGRESSION: TREATMENT • If psychosocial intervention not adequately improve symptoms, consider the following: • Treat primary disorder based upon guidelines • ADHD, Anxiety, Mood Disorders, etc. • Consider Monotherapy with Methylphenidate • If fails, consider amphetamine or alpha 2 agonist • If fails, then consider Atomoxetine • Can combine stimulant with alpha agonist
AGGRESSION: TREATMENT • If still struggling, consider using an atypical antipsychotic • Low dose Risperdal or Abilify are most frequently used • If this fails, consider using the alternative antipsychotic • If this fails, consider augmenting with a mood stabilizer
SELF-INJURIOUS BEHAVIOR (SIB) • Definition: intentional, self-inflicted damage to the body without suicidal intent • Most commonly: cutting, burning, scratching • NSSI - nonsuicidal self injurious behavior
SIB: EPIDEMIOLOGY • Prevalence approximately 14% in school aged sample in 2002 • Not significantly changed since that time • Prevalence rates peak around 15 -16 yo and decline after 18 • Demographics: • Adolescence, female
SIB: RISK FACTORS • Strongest: former SIB, cluster B traits, hopelessness • Strong: previous SI/SA, exposure to peer SIB, abuse • Other factors: bullying, negative social interactions, emotional abuse • Importance: • Significant risk factor for suicide attempts and suicides • Significant risk factor future mental illness even if resolves
SIB: NEUROBIOLOGY • SIB frequently related to difficulty with distress tolerance • Alterations in Hypothalamic-Pituitary Axis (HPA) • Altered Cortisol Response • FMRI • Differentiated processing of social exclusion • Differences in m. PFC and vl. PFC • Patients feel more strongly effected by social exclusion • Different activation of limbic system with stress • Different activation of opioid system (pain offset) • Genetic Factors • Altered function of SLC 6 A 4 with polymorphism of 5 HTTLPR - increased risk for SIB under stressors
SIB: FUNCTION • Automatic Negative Reinforcement (most common reason) • Diminishes negative thoughts or feelings • Automatic Positive Reinforcement • Pleasant thoughts and/or feelings after performing • Social Positive Reinforcement (attention, sending message) • Social Negative Reinforcement (end argument, get out of activities)
SIB: TREATMENT • Medical: wound treatment • Psychotherapy: CBT, DBT-A, MBT-A • All showed improvement at 12 months • ABA or Behavioral Therapy if NDD (Neurodevelopment Disorder) • Medications: No medications approved in USA but off-label usage • Most commonly use SGAs (Second Generation Antipsychotics) if NDD – Risperdal, Abilify • Alpha Agonists – Clonidine – two case reports • Opioid antagonists – Naltrexone – u opioid antagonist blocks release of endogenous endorphins
SIB: TREATMENT PHARMACOTHERAPY • N-Acetylcysteine – antioxidant and prodrug of cysteine • Restores glutathione concentrations in blood and brain • Inhibits glutamate release and reduced inflammation • Antiepileptics • Topiramate – believed to reduce through modulation of GABA and glutamate • Depakote – improves aggression and can improve SIB
- Slides: 35